Diabetes is a chronic illness that requires continuing medical care and education to prevent acute complications and to reduce the risk of long-term complications. People with diabetes should receive their treatment and care from a physician-coordinated team. Such teams include, but are not limited to, physicians, nurses, dietitians, and mental health professionals with expertise and a special interest in diabetes.

The following standards define basic medical care for people with diabetes. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed.

These standards of diabetes care seek to provide:  

• Assess the quality of medical care they receive
• Develop expectations for their role in the medical treatment
• Compare their treatment outcomes with standard goals

For more detailed information, refer to Skyler (Ed.): Medical Management of Type 1 Diabetes (3rd ed. Alexandria, VA, American Diabetes Association, 1998) and Zimmerman (Ed.): Medical Management of Type 2 Diabetes (4th ed. Alexandria, VA, American Diabetes Association, 1998).

SPECIFIC GOALS OF TREATMENT

Type 1 diabetes
The desired outcome of glycemic control in type 1 diabetes is to lower GHb (or any equivalent measure of chronic glycemia) so as to achieve maximum prevention of complications with due regard for patient safety. To achieve these goals with intensive management, the following may be necessary:

• Frequent self-monitoring of blood glucose (SMBG) (at least three or four times per day)
• Medical nutrition therapy (MNT)
• Education in self-management and problem solving
• Possible hospitalization for initiation of therapy

In situations where resources are unavailable or insufficient, referral to a diabetes care team for consultation and/or comanagement is recommended.

Type 2 diabetes
Type 2 diabetes treatment methods should emphasize diabetes management as a multiple risk factor approach including MNT, exercise, weight reduction when indicated, and use of oral glucose-lowering agents and/or insulin, with careful attention given to cardiovascular risk factors, including hypertension, smoking, dyslipidemia, and family history. Whether treated with insulin or oral glucose-lowering agents, or a combination, goals remain those outlined in Table 1.

Table 1. Glycemic Control for People with Diabetes*

Normal Goal Additional action suggested Whole blood values    Average preprandial glucose (mg/dl)    Average bedtime glucose (mg/dl) <100 <110 80-120 100-140 <80/>140 <100/>160 Plasma values    Average preprandial glucose (mg/dl)    Average bedtime glucose (mg/dl) <110 <120 90-130 110-150 <90/>150 <110/>180 HbA1c <6 <7 >8 *The values shown in this table are by necessity generalized to the entire population of individuals with diabetes. Patients with comorbid diseases, the very young and older adults, and others with unusual conditions or circumstances may warrant different treatment goals. These values are for nonpregnant adults. "Additional action suggested" depends on individual patient circumstances. Such actions may include enhanced diabetes self-management education, comanagement with a diabetes team, referral to an endocrinologist, change in pharmacological therapy, initiation of or increase in SMBG, or more frequent contact with the patient. HbA1c is referenced to a nondiabetic range of 4.0­6.0% (mean 5.0%, SD 0.5%).Measurement of capillary blood glucose. Values calibrated to plasma glucose.

INITIAL VISIT
See Table 2 for a summary of the initial visit.

CONTINUING CARE
Continuing care is essential in the management of every patient with diabetes. At each visit, the patient's progress in achieving treatment goals should be evaluated by the health care team, and problems that have occurred should be reviewed. If goals are not being met, the management plan needs to be revised and/or the goals need to be reassessed.

Low-risk, borderline, and high-risk lipid levels for adults are shown in Table 3, and a summary of continuing care is shown in Table 4.

SPECIAL CONSIDERATIONS

Children and adolescents
Approximately three-quarters of all newly diagnosed cases of type 1 diabetes occur in individuals younger than 18 years. Care of this group requires integration of diabetes management with the complicated physical and emotional growth needs of children, adolescents, and their families. Diabetes care for children of this age-group should be provided by a team that can deal with these special medical, educational, nutritional, and behavioral issues.

At the time of initial diagnosis, it is extremely important to establish the goals of care and to begin diabetes self-management education. A firm educational base should be provided so that the individual and family can become increasingly independent in the self-management of diabetes. Glycemic goals may need to be modified to take into account the fact that most children younger than 6 or 7 years have a form of "hypoglycemic unawareness," in that they lack the cognitive capacity to recognize and respond to hypoglycemic symptoms. Intercurrent illnesses are more frequent in young children. Sick-day management rules must be established and taught to prevent severe hyperglycemia and diabetic ketoacidosis (DKA) that require hospitalization. A nutritional assessment should be performed at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets. Caution must be exercised to avoid overaggressive dietary manipulation in the very young. Assessment of lifestyle needs should be accompanied by possible modifications of the diabetic regimen. For example, an adolescent who requires more flexibility might be switched to a three­ or four­insulin-injection program when needed.

A major issue deserving emphasis in this age-group is that of "adherence." No matter how sound the medical regimen, it can only be as good as the ability of the family and/or individual to implement it. Health care providers who care for children and adolescents, therefore, must be capable of evaluating the behavioral, emotional, and psychosocial factors that interfere with implementation and then must work with the individual and family to resolve problems that occur and/or to modify goals as appropriate.

Information should be supplied to the school or day care setting so that school personnel are aware of the diagnosis of diabetes in the student and of the signs, symptoms, and treatment of hypoglycemia. It is desirable that blood glucose testing be performed at the school or day care setting before lunch and when signs or symptoms of abnormal blood glucose levels are present.

For further discussion, see the American Diabetes Association's position statement, "The Care of Children With Diabetes in the School and Day Care Setting." (Diabetes Care 23 [Suppl 1]:S100-103, 2000).

Referral for diabetes management
For a variety of reasons (e.g., intercurrent illness, DKA, recurrent hypoglycemia), it may not be possible to provide care that meets these standards or achieves the desired goals of treatment (Table 1). In such instances, additional actions suggested may include enhanced education of diabetes self-management, comanagement with a diabetes team, or referral to an endocrinologist.

Intercurrent illness
The stress of illness frequently aggravates glycemic control and necessitates more frequent monitoring of blood glucose and urine ketones. Marked hyperglycemia requires temporary adjustment of the treatment program, and, if accompanied by ketosis, frequent interaction with the diabetes care team. The patient treated with oral glucose-lowering agents or MNT alone may temporarily require insulin. Adequate fluid and caloric intake must be assured. Infection or dehydration is more likely to necessitate hospitalization of the person with diabetes than the person without diabetes. The hospitalized patient should be treated by a physician with expertise in the management of diabetes.

Diabetic ketoacidosis and hyper-osmolar hyperglycemic nonketotic syndrome
These conditions represent decompensation in diabetic control and require immediate treatment. Careful evaluation of the patient for associated or precipitating events must be undertaken (e.g., infection, medications, vascular events), and associated problems must be treated appropriately. Depending on the severity of the illness and available resources, treatment can be initiated in the physician's office, but it is best carried out in the emergency room, hospital room, or intensive care unit. Because of the potential morbidity and mortality of DKA and the hyperosmolar hyperglycemic nonketotic syndrome, prompt consultation with a diabetologist/ endocrinologist is recommended when the initial clinical and/or biochemical state is markedly abnormal, when the initial response to standard therapy is unsatisfactory, or when metabolic complications or cerebral edema occur. Recurrence of DKA demands a detailed psychosocial and educational evaluation by a diabetes specialist.

Severe or frequent hypoglycemia
The occurrence of severe, frequent, or unexplained episodes of hypoglycemia may be due to a number of factors such as defective counterregulation, hypoglycemic unawareness, insulin dose errors, and excessive alcohol intake. Hypoglycemia may also be a consequence of the therapeutic regimen and always requires evaluation of both the management plan and its execution by the patient. Family members and close associates of the patient who uses insulin should be taught to use glucagon.

The successful accomplishment of these goals requires more frequent patient contacts during readjustment of the treatment program and patient/family reeducation.

Pregnancy
To reduce the risk of fetal malformations and maternal and fetal complications, pregnant women and women planning to become pregnant require excellent blood glucose control. These women need to be seen frequently by a multidisciplinary team, including a diabetologist, internist or family practice physician, obstetrician, diabetes educators, including a nurse, registered dietitian, and social worker, and other specialists as necessary. In addition, these women must be trained in SMBG and may require specialized laboratory and diagnostic tests. For further discussion, see the American Diabetes Association's position statement "Preconception Care of Women with Diabetes." (Diabetes Care 23 [Suppl 1]: S65-68, 2000.)

Because of the need for prepregnancy planning and excellent glucose control, every pregnancy in a woman with diabetes should be planned in advance. Therefore, any diabetic woman who is not currently attempting to conceive should be informed of and offered acceptable and effective methods of contraception.

For information on gestational diabetes mellitus, see the American Diabetes Association's position statement on this topic.(American Diabetes Association: Gestational diabetes mellitus [Position Statement]. Diabetes Care 23 [Suppl 1]:S77-79, 2000.)

RETINOPATHY
In addition to undergoing the annual retinal examination by an ophthalmologist or optometrist who is knowledgeable and experienced in the management of diabetic retinopathy, patients with any level of macular edema, severe nonproliferative retinopathy, or any proliferative retinopathy require the prompt care of an ophthalmologist who is knowledgeable and experienced in the management of diabetic retinopathy. For further discussion, see the American Diabetes Association's position statement (American Diabetes Association: Diabetic retinopathy [Position Statement]. Diabetes Care 23 [Suppl 1]:S73-76, 2000.)

HYPERTENSION
Hypertension contributes to the development and progression of chronic complications of diabetes. In patients with type 1 diabetes, persistent hypertension is often a manifestation of diabetic nephropathy, as indicated by concomitant elevated levels of urinary albumin and, in later stages, by a decrease in the glomerular filtration rate (GFR). In patients with type 2 diabetes, hypertension often is part of a syndrome that includes glucose intolerance, insulin resistance, obesity, dyslipidemia, and coronary artery disease. Isolated systolic hypertension may occur with long duration of either type of diabetes and is in part due to inelasticity of atherosclerotic large vessels. Control of hypertension has been demonstrated conclusively to reduce the rate of progression of diabetic nephropathy and to reduce the complications of hypertensive nephropathy, cerebrovascular disease, and cardiovascular disease.

General principles
Lifestyle modifications should initially be employed to reduce blood pressure unless hypertension is at an urgent level. Such modifications include weight loss, exercise, reduction of dietary sodium, and limits on alcohol consumption. If lifestyle modifications do not achieve specified goals, medications should be added in a stepwise fashion until blood pressure goals are reached. Several medications in patients with albuminuria (e.g., ACE inhibitors) appear to have selective benefit in patients with diabetes. Other cardiovascular risk factors, such as smoking, inactivity, and elevated LDL cholesterol levels, should also be managed concomitantly.

Specific goals of treatment
The primary goal of therapy for adults should be to decrease blood pressure to <130/85 mmHg. In children, blood pressure should be decreased to the corresponding age-adjusted 90th percentile values.

Hypertension in adults has traditionally been defined as a systolic blood pressure >140 mmHg and/or a diastolic blood pressure >90 mmHg. Most epidemiological studies have suggested that risk due to elevated blood pressure is a continuous function, so these cutoff levels are arbitrary. In the general population, the risks for end-organ damage appear to be lowest when the systolic blood pressure is <120 mmHg and the diastolic blood pressure is <80 mmHg.

For patients with an isolated systolic hypertension of >180 mmHg, the goal is a blood pressure <160 mmHg. For those with systolic blood pressure of 160­179, the goal is a reduction of 20 mmHg. If these goals are achieved and well tolerated, further lowering to 140 mmHg may be appropriate. (For more detailed information, see the consensus statement "Treatment of Hypertension in Diabetes." [Diabetes Care 16:1394-1401, 1993.])

NEPHROPATHY

General principles
Persistent albuminuria in the range of 30­300 mg/24 h (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy and is a significant risk marker for cardiovascular disease. Patients with microalbuminuria will likely progress to clinical albuminuria (>300 mg/24 h) and decreasing glomerular filtration rate (GFR) over a period of years. Once clinical albuminuria occurs, the risk for end-stage renal disease (ESRD) is high in type 1 diabetes and significant in type 2 diabetes. If untreated, hypertension can hasten the progression of renal disease. Over the past several years, a number of interventions have been demonstrated to retard the initial development or rate of progression of renal disease.

Specific goals of treatment
Intensive diabetes management with the goal of achieving near normoglycemia has been proved to delay the onset of microalbuminuria, and the progression of microalbuminuria to clinical albuminuria, in patients with type 1 diabetes.

Lowering blood pressure to <130/85, by any effective means, should be the goal in hypertensive individuals. A reduction in blood pressure will also decrease the rate of progression of diabetic nephropathy.

In hypertensive patients with either type 1 or type 2 diabetes who have microalbuminuria or clinical albuminuria, treatment with ACE inhibitors has been shown to delay progression from microalbuminuria to clinical albuminuria and to slow the decline in GFR in clinical albuminuria. Because of the high proportion of patients who progress from microalbuminuria to overt nephropathy and subsequently to ESRD, the use of ACE inhibitors is recommended for all type 1 patients with microalbuminuria, even if they are normotensive. However, because of the more variable rate of progression from microalbuminuria to overt nephropathy and ESRD in patients with type 2 diabetes, the use of ACE inhibitors in normotensive type 2 diabetic patients is not as well substantiated as in normotensive type 1 diabetic patients. Therefore, treatment with ACE inhibitors in normotensive type 2 patients should be based on physician assessment. Should such a patient show progression of albuminuria or develop hypertension, then ACE inhibitors would clearly be indicated.

The albumin-to-creatinine ratio can be measured in a random urine specimen. Alternatively, measurement of urine albumin may be done on a 24-h or other timed urine collection. There is marked day-to-day variability in albumin excretion, so that at least two of three collections measured in a 3- to 6-month period should show elevated levels before a patient is designated as having microalbuminuria. Abnormalities of albumin excretion are defined in Table 5.

Assessment of the creatinine clearance should be performed by using the serum creatinine and formulas that take into account the patient's age, sex, and body size or by measuring creatinine in serum and in a timed urine specimen.

Repeat timed or overnight urine collections or measurements of albumin-to-creatinine ratios should be obtained periodically to document the effect of treatment on albumin excretion and to detect the rare case of a deleterious effect of drug therapy. If ACE inhibitors are used, serum potassium levels should also be monitored for the development of hyperkalemia, with an increased frequency of monitoring when there is a progressive decrease in GFR or in patients with hyporeninemic hypoaldosteronism.

Protein restriction to 0.8 g ? kg^­1 body wt ? day^­1 (~10% of daily calories), the current adult recommended daily allowance for protein, should be instituted with the onset of overt nephropathy. However, it has been suggested that once the GFR begins to fall, further restriction to 0.6 g ? kg^­1 body wt ? day^­1 may prove useful in slowing the decline of GFR in selected patients. On the other hand, nutritional deficiency may occur in some individuals and may be associated with muscle weakness. Protein-restricted meal plans should be designed by a registered dietitian familiar with all components of the dietary management of diabetes.

Referral to a physician experienced in the care of diabetic renal disease should be considered when the GFR has fallen to either <70 ml ? min^­1 ? 1.73 m^­2, when serum creatinine has increased to >2.0 mg/dl (>180 µmol/l), or when difficulties occur in management of hypertension or hyperkalemia. (For a complete discussion on the treatment of nephropathy, see American Diabetes Association: Diabetic nephropathy [Position Statement]. Diabetes Care 23 [Suppl 1]:S69-72, 2000.)

CARDIOVASCULAR DISEASE
Evidence of cardiovascular disease, such as angina, claudication, decreased pulses, vascular bruits, and electrocardiogram abnormalities, requires efforts to correct contributing risk factors (e.g., obesity, smoking, hypertension, sedentary lifestyle, dyslipidemia, poorly regulated diabetes) in addition to specific treatment of the cardiovascular problem. Daily intake of aspirin has been shown to reduce cardiovascular events in patients with diabetes.( For specific recommendations and further discussion, see American Diabetes Association: Aspirin therapy in diabetes [Position Statement]Diabetes Care 23 [Suppl 1]:S61-62, 2000.)

Although evidence from randomized controlled studies is lacking, the American Diabetes Association Consensus Development Conference on the Diagnosis of Coronary Heart Disease in People With Diabetes has recommended that patients with an established coronary heart disease (CHD) history or who have had a prior cardiac event warrant cardiac testing for risk stratification. Further, in patients without a prior history of an event or symptoms strongly suggesting CHD, testing for CHD is warranted in patients with the following: 1) typical or atypical cardiac symptoms; 2) resting electrocardiogram suggestive of ischemia or infarction; 3) peripheral or carotid occlusive arterial disease; 4) sedentary lifestyle, age >35 years, and plans to begin a vigorous exercise program; and 5) in addition to diabetes, two or more cardiac risk factors (total cholesterol >240 mg/dl, LDL cholesterol >160 mg/dl, or HDL cholesterol <35 mg/dl; blood pressure >140/90 mmHg; smoking; family history of premature CHD; positive micro-/macroalbuminuria test). Cardiac testing might consist of exercise stress testing, stress perfusion imaging, stress echocardiography, or catheterization. The type of testing and need for referral to a cardiologist depend on the severity of underlying or suspected coronary artery disease. (For further discussion, see American Diabetes Association: Diagnosis of Coronary Heart Disease in People With Diabetes [Consensus Statement]. Diabetes Care 21:1551-59, 1998.)

DYSLIPIDEMIA

General principles
Diabetes increases the risk for atherosclerotic vascular disease. This risk is greatest in people who have other known risk factors, such as dyslipidemia, hypertension, smoking, and obesity. Furthermore, in type 2 diabetes there is an additional increased risk for obesity and lipid abnormalities independent of the level of glycemic control. A common abnormal lipid pattern in such patients is an elevation of VLDL, a reduction in HDL, and an LDL fraction that contains a greater proportion of small, dense LDL particles.

Data about treatment of dyslipidemia in people with diabetes, especially in children, are limited. However, current recommendations from the National Cholesterol Education Program Adult Treatment Panel II Report and the Expert Panel on Blood Cholesterol Levels in Children and Adolescents Report on the general management of elevated cholesterol and triglycerides have set increasingly stringent treatment targets based on the number of cardiovascular risk factors and the presence of CHD. Risk factors include age (men >45 years or women >55 years, or premature menopause without estrogen replacement therapy), diabetes mellitus, hypertension, HDL cholesterol <35 mg/dl (<0.90 mmol/l) in men and <45 mg/dl (<1.15 mmol/l) in women, smoking, microalbuminuria, and a family history of premature CHD. Because diabetes appears to eliminate the protective effect of female sex against CHD, all adults with diabetes are candidates for progressively aggressive therapy.

The following recommendations are designed to achieve two major goals as a result of treatment of dyslipidemia: 1) to reduce the risk for development of CHD in people without documented CHD and 2) to reduce the risk for progression of CHD or to cause regression in people with known CHD.

A meal plan designed both to lower glucose levels and to alter lipid patterns and regular physical activity are the cornerstones in the management of lipid disorders. The goal of MNT should focus on three major strategies: weight loss if indicated, increased physical activity, and MNT individualized for the patient.

Weight loss is achieved by reducing total caloric and fat intake and by increasing physical activity. Recommendations for increased physical activity, however, need to be made in the context of the patient's history and medical status. The recommendations should detail a frequency, duration, and intensity of exercise. Lipid-lowering pharmacological agents are indicated if there is an inadequate response to a trial of MNT, exercise, and improved glucose control. (For a complete discussion of the treatment of lipid disorders, see American Diabetes Association: Management of Dyslipidemia in Adults With Diabetes [Position Statement]. Diabetes Care 23 (Suppl 1):S57-60, 2000.)

The primary emphasis in children and adolescents with serum lipid abnormalities should be on glucose control, MNT, and exercise. Because there are important considerations regarding the efficacy and safety of drug therapy for dyslipidemia in children and adolescents, drug therapy in these individuals should be undertaken only in consultation with a physician experienced in the area of lipid disorders in children.

Specific goals of treatment
The primary goal of therapy for adult patients with diabetes is to lower LDL cholesterol to <100 mg/dl (< 2.60 mmol/l).

People with diabetes who have triglyceride levels >1,000 mg/dl (> 11.3 mmol/l) are at risk of pancreatitis and other manifestations of the hyperchylomicronemic syndrome. These individuals need special, immediate attention to lower triglyceride levels to <400 mg/dl (<4.50 mmol/l). Further reduction to Adult Treatment Panel II goals of <200 mg/dl (<2.30 mmol/l) may be beneficial.

A secondary goal of therapy is to raise HDL cholesterol to >45 mg/dl (>1.15 mmol/l) in men and >55 mg/dl (>1.40 mmol/l) in women.

The primary goal of therapy for children with risk factors in addition to diabetes is to lower LDL cholesterol to <110 mg (<2.80 mmol/l), following the recommendations of the National Cholesterol Education Program's Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents.

NEUROPATHY
Peripheral diabetic neuropathy may result in pain, loss of sensation, and muscle weakness. Autonomic involvement can affect gastrointestinal, cardiovascular, and genitourinary function. Each condition may require special diagnostic testing and consultation with an appropriate medical specialist. Improvement in neuropathy should be sought by increased attention to blood glucose control. Relief can be provided by various medications, alterations in MNT, or specialized procedures.

FOOT CARE
Problems involving the feet may require care by a podiatrist, orthopedic surgeon, vascular surgeon, or rehabilitation specialist experienced in the management of people with diabetes. All patients, especially those with evidence of sensory neuropathy, peripheral vascular disease, and/or altered biomechanics must be educated about the risk and prevention of foot problems, and this education must be regularly reinforced.

Patients with a history of previous foot lesions, especially those with prior amputations, require preventive foot care and lifelong surveillance, preferably by a foot care specialist. (For a complete discussion on foot care, see American Diabetes Association: Preventive Foot Care in People With Diabetes [Position Statement]. Diabetes Care 23 [Suppl 1]:S55-56, 2000.)